24667 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO - n,Dl i-BU TRIAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB ING-NRCHANICAL A
BUILDING PROJECT IDENTIFICATION G/J 4
667
BU INO D ESS: 00�0 - SANITARY NO. APPLICATION SUBMITTAL BATR
u # Lor x I r �
OW ER/JS NA /(., PHO E: �J ACT,ORy:S NAME/: LIC NO:
/I• f A �j�P ���G.Iy� C17//�i,� N/C CONTROI.p
4RCHII'F( yiNOINEER: LIC NO: ADDRESS: _
CONTACT: 'PHONE: QTY. ELECfRIC PERMIT FEE BUILDING PERMIT INFO
1 DLDp L CCT PLUMB MECH
'
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION pPPLIANCHS-RF.SIDPNI'IA
I here affirm that l am lvesioedunder p gwi JOB DESCRIPTION
OCZ by provisions efCha mr9(cnmmencin N 2 - _r_�rr _
�d00 SeC0on9110idef Division Jnrlhe Business and Profess e,e m limn#is in I� \f//(,x''�l-1sT.[.-7-1 T7r
�� 9f1-Y P .IS
yqqF full fo¢e unA effect C..LicIra)-1 21) MP
ti?yVy Dlatenx CP Con 2 -I 1(1S
ARCHITECTS DECLARATION 5Q.IT.FLOOR AREA $. FI'.
Z O y a 1 understand my plans shut[he used as public records. Sl EN 1. AMI
ozro
Fyn41 SI'NS CI. ALNALED
QY Licensed Professional
CC y'as6 OWNER-BUILDER DECLARATION SPECIALPTR T ISG. (fin
kOy F I hereby M.That 1 inn exempt from the Connector's License law for the V e
B1a�wa following reason.(Sectio a 9031,5,Business and Professions Code:Any city or county �TCMP.M OR POL I,�+
whichrequina.permitticcon...roan,.ler.improve,Aemolislhor repair any slrcmre - �V\V\
;!ZY2 prier to its issuance,also requires the applicant for such permitto File a signed statement PoWCRB VI TE
f a a O that he is licensed pursuant o the provisions of the Conlecsoes License Law(Chapter
d KOo� 9(commencing with Section 10001 of Division 3 of the Business and Professions Cole) WIMNIING POOL ELECTRIC VAON
W•_y or that he is exempt therefromondth,basis for the alleged exemption.Any violation of11TI pT5-SWITCIiFS-FIXTURES
noco
Q
i Section 9113 L5 by any appliermfor.permit subjects lhe.pplicant to a civil penalty of V
At namethan B ve bombed dollars($500). V
tY ❑ Lasown<rnftheprnperty,nrmyemplreeswith wagesastheirsolecompeicamme, NEW kESIDENTIAL ELECTR _SQ.FT. S'T'ORIES TYPE CONSTRUCTION
y will do the work,und the structure is not hneadedoroffered forrale(See.9W4,Business
and Professinm Code:The Conlraemrs License Law doa net apply to an owner of
progeny whobuildsorimproves thein.gand whodoea suchwork himse[forthmugh his
own employees,provided that such improvements uncial lntendedoroffeind forsale.If, OCC.GROUP RES.UNITS
however,the building or impmvcment ie sold within one yam mcompledmi,the owner- .[.
builder will have the bu len ofproving that he did not build or improve for purpose of -
ale.).
❑ I,aurwn<rnfthepropeny,umexdusivdycommcting withlittnsM convanorsr QTY. PLUMBING PERMIT FF,Ii FLOOD ZONE APN
construct the project(Sec.IDW,Business and Professions Cale:)The Contruclors PERMIT ISSUANCE �
License Law does not apply loan ownerofproper,whobuilds orimprove.,dareon,and
who cnmmmsfnrsuch pmjcctswhhuconuumrfsl liccnmd punuvnuothe Contmcr8s pRAIN@VEN'T-WATCR(EA)
License Law, ALTER- FERSUMMARY
❑ I am exempt under Sec. ,B @ P C for this reason BACK PLOW PROTECT.DEVICEG IDE.FF.F
SANITARY Y N
Owner Dale DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPFNSA'I'ION DECLARATION SCHOOLTAX YN
❑ Thereby affirm Chat[havenccnificam of nmmnuoselGinsum,
jr a'
of FI%TUNI?S-PF.R TRAP /a RECEIPT'#
Workere'Cnmpenemian lnsnrnce oraxertiFiW cnpythmeof(See.3800,1abO)which PARKFI?I? ,Y
_N
covers all employee's under this pemmit' GAS-IA,SYSTEM-1 INC.4 OUTLETS RECEIPT'#
Policytl BUILDING DIVISION FEES
Company GAS-F.A.SYSTEM-OVRR 4(EA) PLANCHECK FEE
❑ CcNEeicopyi.sherebyfueished.
❑ CeniBed copy is filed with the city inspeninn division. CRFASIONDUSTRLWASTEINTERCr.M'OR GRADING FEE
CERTIFICATE OI'EXEMPTION FROM WORKERSGREASE'I RAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forone hundred dollars(SIM) SEWER-SANITARY-STORM EA.200PT. ENERGY TEE
or less.)
I expiry that in the Performance ofthe work for which Ibis pemmil is issued,I shall WATER HEATER WNENI'/ELRCIR
not employ any person in any m as m become subject to the WmkelK PAID
mpenaition Luws of @lifomia. Dau sn WATER SYSTEM/TRHA1'ING Date - Beretta#
plioant
z NOTICE GO APPLICANT Bursae making this CeniBcateof Exemption,you should NEW RFSIDENTIALPI.MB SQ PT. TOTAL:
L•-' V_] become subject to the Worlo,s Compensation provisions ofth,Labor Ends,you must
fenhwith comply with such provisions or this permit shall be deemed invoked. BUILDING FEE _�_
LLj 'SEISMIC FEE
CONS there
LENDING AGENCY m� V
5 I hereby hick this
Permit
is i construction 3 lending97, ivagency for the performance of
L) O the work for which this permit iz issued(Sec.3099,Civ.CJ � A ' ELECTRIC IFC
f- Lender's Name
0 t' Leadds Address Q'rY. MECHANICALPERMIT FEE PLUMBING IFF.
FU$1 1 cenify the 1 have red this application onA amore that the we information ix MHCIIANICAL FEF.
a correct Ingreemromply with all city and county ordinance. nate tree relating to PF:RM1'I'ISSUANCE
_ building vaimm ori,and hcrcby uuthnrim represetnmiv iscitylnenmruponthe CONSIRIICTIDN TAX
U z above-mentioned property for inspection purposes. ALTI?R OR ADD TO Mf:CII.
(We)egin ,indemnify and keep h the City of Cupertino against
Babilines,ju s costs in d expenseswhic a any wey¢emeag.iest said City AIR I IANDLING UNIT(TO 10.000 CFM)
in cons nIh ranlingofthispe
_ AIR HANDLING UNIT(OVER IRWO CFM)
is
EXHAUST I IOODOODUCT,
gnamrc 1 ApplunnVCommd Data PAID
HAZARD ATERIAISDISCLOSURE HEATING UNI'I'(TO IW,1lflo BTU) Date Receipt#
Will the applicant or future building nccup.nl store m handle hasardous material
as defined by the Cupertino Municipal Code,Ch.pmr 9.12,and the l health and Safety HEATING UNIT(OVER 100,000 BTU) T
Code,Section 25532(a)Y - VENTILATION FAN(SINGLL'kfiSlD) t
❑Yes ❑ No
BOILER-COMP(3HPORIW,a BTU) ISSUANCE DATE
Will the applicant or future buildingoccupen usecquipncrumdame.whichernit I A sa,
>ishict9
hossid as air aouteminan.ss defend by the Ray Ara AG Quality Management BOILER-COMP(OVER IIXI,IXKI BTU) W u
���S ❑Yes ❑No NEW RESIDENTIAL MECII, SQ.IT. 11 ���
I Jewc read the hvarinus mmerials requirements under Chapter fi 95 of 0e 3
California Ilealth @ Sefery Cale.Sections 25503,2551]anJ 25SJ4. I undersmnd that
Hthe building does not curtem[y have a Icnanl,that it is my responsibility to notify the '
occupant of the ree mo meet,which mum be met prior to issuance of a Certificate of CUrcn 111#V
Occupancy.
Owner or umhnrimd agent ISSUED IiY:
OFFICE